The clinical commissioning groups in Leeds (Leeds North CCG, Leeds South & East CCG and Leeds West CCG) agreed to work with their one hundred and eleven member GP practices to increase the number and quality of patient safety incident reports and significant event audits that were shared with the CCG.
Aims and objectives
Increase the number of medicines related patient safety incident reports that general practices submitted to the CCGs in 2014/15 to in excess of 1 per 100,000 head of patient population (~820 reports).
Reasons for implementing your project
Primary care providers contribute only a fraction of the patient safety incident reports received by the National Reporting and Learning System (NRLS). In 2011 general practices in England reported just 4154 patient safety incidents to the National Reporting and Learning System (NRLS). Many practices regularly review patient safety incidents using a process similar to root causes analysis called significant event audit (SEA).
The GP practices in our CCGs reported 144 medicines related incidents to the CCGs in 2013/14 was 144. This level of reporting is much lower that would have been expected for the registered population of 820,000 patients and the number of consultations and interactions that take place.
The PRACtICe study estimates that 1 in 8 patients are affected by a medication error in general practice. Although it was appreciated that practices were under no obligation to report to the CCG it was considered that this rate represented significant underreporting of the number of errors that were estimated to be occurring and offered little opportunity to identify ways in which the CCG could tackle avoidable hospital admissions resulting from Adverse Drug Reactions.
How did you implement the project
The CCGs drew on the experience of the medicines optimisation teams (of which the medicines safety function is shared across the 3 CCGs) and primary care teams to direct the existing methods of changing behaviour that have worked in primary care to the objective of increasing incident reports. The CCGs employ a pharmacist with specialist knowledge in patient safety who was able to advise on effective strategies. As a result the CCGs launched a programme of support for general practices.
The programme was delivered by the medicines optimisation teams, primary care development teams and the governance team for the CCGs. The programme included clinical leadership, reporting infrastructure, human factors training, feedback based on knowledge transfer principles and an incentive scheme.
Each CCG included medicines related incident reporting as part of practice engagement scheme. The target was to report 3-5 incidents per 100,000 registered population (actual target dependent on the aspirations of each CCG). There was no direct payment for the incidents, however unless the practice achieved the target they were not eligible for any payment for other elements of the scheme
The training in human factors was provided by the specialist medicines safety pharmacist and focussed on the Yorkshire Contributory Factors Framework (http://www.improvementacademy.org/patient-safety/safety-incident-framework.html) supplemented by error theory described by leaders in patient safety such as James Reason. (see CHFG.org for more information on Human Factors in Healthcare)
Feedback was considered crucial to success. Thematic review and analysis of submitted significant event audits gave the opportunity to publish, on a monthly basis case studies from which practices could extract and apply safer practice. These were consistently formatted and the link between ‘reporting’ and the provision of lessons in case studies was made explicit.
- GP practices reported 1724 medicines related issues to the CCGs in 2014/15. The baseline figure from 2013/14 was 144.
- 75% of the incidents were “internal issues”, things that went wrong within the circle of control of the practice. 94% of these incidents are classed as no-harm incidents.
- The practices submitted 517 significant event audits detailing lessons learnt.
- The lessons derived from incident reports and submitted in significant event audit were published in PowerPoint presentation on a monthly basis (see supporting material)
Key learning points
- The NPSA guidance; Seven Steps to Patient Safety for Primary Care, advises that patient safety incident reporting is fundamental to trying to learn what is contributing to patient harm. Our programme to improve the number of incident reports submitted to the CCGs by general practices has been successful.
- Human Factors training offered a fresh perspective for practices to re-invigorate incident reporting and significant event audit.
- The focused and multi-faceted campaign by the CCGs ensured that all the general practices were able and motivated to submit incident reports.
- The next steps are to improve the quality of the reports and the associated SEA and to develop plans for sustaining the levels of reporting.